US Secretary of State Hillary Clinton spoke Aug. 16, 2010, at the John Hopkins School of Advanced International Studies in Washington, DC, to outline the US policy in global health and how it marries with the country’s foreign policy objectives.

Global Health Initiative
Her comments follow the announcement by President Barack Obama in May 2009 of the Administration’s funding for the US Global Health Initiative (GHI), a dedicated effort by the US government in global health that seeks to create an integrated, coordinated, sustainable system of care in working with developing countries in providing assistance related to health and healthcare. The plan includes funding of $63 billion for six years (fiscal year 2009 through fiscal year 2014). The Administration launched the GHI as part of a policy that seeks to create better cohesion among US efforts, develop new tools and technologies for delivering assistance, and desing better models in providing in aid. “We cannot simply confront individual preventable illnesses in isolation,” said Obama on May 5, 2009, in a prepared statement. “The world is interconnected, and that demands an integrated approach to global health.”

In her comments in August 2010, Clinton emphasized that global health plays an important role in the country’s foreign policy and national security interests. “We invest in global health to strengthen fragile or failing states,” she said, pointing to the destabilizing effect that national health crises can have on a country such as in the impact of HIV/AIDS. “…We invest in global health to promote social and economic progress and to support the rise of capable partners who can help us solve regional and global problems,” she added. “….We invest in global health to protect our nation’s security,” pointing to the need for effective global health systems for tracking health data, monitoring threats, and coordinating response such as in the case of severe acute respiratory syndrome (SARS) and the H1N1 virus. “We invest in global health as a tool of public diplomacy…Giving people a chance at a long and healthy life or helping protect their children from disease conveys as much about our values as any state visit or strategic dialogue ever could,” she said.

Progress report
Clinton provided an update of on the progress and future direction of GHI. “The United States is investing $63 billion—first, to sustain and strengthen our existing health programs, and second, to build upon those programs and take their work to the next level by collaborating with governments, organizations, civil society groups, and individuals to help broaden the improvements in public health that we can expect,” she said. “We're shifting our focus from solving problems, one at a time, to serving people, by considering more fully the circumstances of their lives and ensuring they can get the care they need most over the course of their lifetimes. ...

She pointed to several efforts underway, including the United States President’s Emergency Plan for AIDS Relief (PEPFAR), which was formed in 2003 under George W. Bush and has continued under the current Administration. In 2008, funding for PEPFAR was $5 billion, and the budget request for fiscal year 2011 is $5.7 billion to meet a goal of raising the number of people served under the program to 12 million. She added that the Administration is increasing support for the President’s Malaria Initiative (PMI) with the goal of reducing the burden of malaria by 50%, or by 450 million people. PMI was launched in June 2005 by President Bush as a five-year, $1.2-billion program to scale up malaria prevention and treatment interventions in 15 high-burden countries in sub-Saharan Africa. Clinton also pointed to goals of increasing prevention of tuberculosis (TB) and efforts to improve child and maternal health.

These specific goals of GHI and others are detailed by the US Agency for International Development (USAID). USAID is an independent agency that provides economic, development, and humanitarian assistance globally in support of the foreign policy goals of the United States. USAID details key goals in several areas:

• HIV/AIDS: Through PEPFAR, support the prevention of more than 12 million new HIV infections, provide direct support for more than 4 million people on treatment, and support care for more than 12 million people, including 5 million orphans and vulnerable children

• Malaria: Through PMI, reduce the burden of malaria by 50% for 450 million people, representing 70% of the at-risk population in Africa, and expand malaria efforts into Nigeria and the Democratic Republic of the Congo

• TB: Save approximately 1.3 million lives by reducing TB prevalence by 50% by treating 2.6 million new TB cases and 57,200 multidrug resistant cases of TB

• Nutrition: Reduce child undernutrition by 30% in assisted food-insecure countries, in conjunction with the President's Feed the Future Initiative, a federal program for providing nutrition support to the developing world

• Neglected tropical diseases: Reduce the prevalence of seven neglected tropical diseases by 50% among 70% of the affected population and eliminate onchocerciasis in Latin America by 2016 and lymphatic filariasis and leprosy globally by 2017

• Reproductive health: Reduce first births by women under the age of 18 to 20% and increase contraception in assisted countries.

Policy implementation
Clinton emphasized that meeting the goals of GHI requires addressing systemic challenges that surround PEPFAR, USAID programs, and other US-funded health programs by improving logistical, structural, legal, and political barriers that may be preventing the implementation of aid. “We need to lay the groundwork now for more progress down the road by tackling some of these systematic problems and working with our partner countries to uproot the most deep-seated obstacles that impeded the own people’s health,” she said. “That is how we can make our investments yield the most significant returns and save the greatest number of lives, today and tomorrow.”

Clinton outlined six key ways in which the Administration is pursuing these goals. The first way involves capacity-building. Under this approach, the US is working with countries to create and implement strategies for health based on the distinct needs and existing strengths of assisted countries by building their healthcare capacity toward the goal of managing, overseeing, coordinating, and operating health programs for the long term. These efforts may involve training of community health workers, setting up supply chains and drug protocols, and establishing health-information systems to collect and analyze data to allow for continuous monitoring and improvement of performance.

A second effort involves improving maternal and child health, particularly for girls, by improving access to healthcare by addressing educational, economic, social, and cultural barriers that may impede that access. Clinton said the US is working with governments, civil society groups, and individuals, including national health ministers, healthcare administrators, and healthcare providers to ensure that women and girls are considered when forming healthcare policy and spending allocation in assisted countries.

A third effort addresses the way the US measures and evaluates its own impact. “This includes shifting our focus from ‘inputs’ to ‘outcomes and impacts’—that is determining our success not simply by how many bed nets we distribute but by how many people actually avoid malaria by using them correctly–a fuller picture that demands that we invest in improving how we ourselves collect, analyze, and share data,” said Clinton.

Clinton said that another focus would be to invest in innovation to develop tools that help diagnose, prevent, and cure disease in communities where aid is administered, particularly in areas that are remote and poor in resources. “Many of the tools and techniques we use to keep people healthy here in the United States are unsuited to the realities of life in other places,” she said. “So we need to be innovative about how to reach people effectively.” For example, Clinton pointed to the use of cell phones in remote areas that may lack health clinics as a tool for communicating critical health messages directly to patients such as women with newborns.

A fifth goal is to improve coordination and integration within and among US agencies by bundling services. She pointed to PEPFAR’s efforts in Kenya by linking HIV/AIDS programs with maternal and child health, TB, and family planning. She also pointed to the importance of involving multiple federal agencies in GHI, whose overall policy is directed by US Deputy Secretary of State Jack Lew. Day-to-day operations of GHI are run by Raj Shah, USAID administrator, Eric Goosby, US global AIDS coordinator of PEPFAR, and Tom Frieden, director of the Centers for Disease Control. Other agencies, including the National Institutes of Health, the Department of Health and Human Services, the Department of Defense, and the Peace Corps are also involved in the effort.

The sixth point made by Clinton is of the need to align US efforts with other donor countries and multilateral organizations. She pointed to the public–private partnership, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, as an example of “creating a new model for how the global community can come together to contribute and coordinate in the fight against epidemics.”

In concluding comments, Clinton emphasized the interrelationship between global health, US diplomacy, and US relations with countries receiving aid. “Too often, we’ve seen health relegated to the sidelines and treated as a lesser priority in terms of how much money is allocated and how much attention is devoted,” she said. “In fact, we’ve seen that the United States and other donors come in with money, and countries actually take money away from health thinking that we’re going to make up the difference. The United States is willing to invest our money, our time, and our expertise to improve health in countries, but were are now asking governments to demonstrate a similar commitment in terms of human resources, serious pledges to build capacity, and where feasible, financial support.”